After School Program (A.S.P.) Registration - Program starts August 30th!

Due to the generosity of our community, the Youth Center continues to
provide low-cost supervised after school program and learning center
services to children 7-17 years old. (Our RASCALS program at Rossmoor park
is designed for elementary school aged children and there is a separate form
to register a child for RASCALS.) All children must be registered so we
maintain contact and other information. There is a small monthly supply fee
that is required that we use to cover supplies. Scholarships are available
to qualified families.

Emergency Information, Indemnity & Consent Release

INDEMNITY AND HOLD HARMLESS AGREEMENT

I/we hereby grant permission for my child to participate in the Los Alamitos Youth Center, Inc. program for which I am registering. I agree to indemnify and hold harmless the Los Alamitos Youth Center, City of Los Alamitos, Los Alamitos Unified School District, Rossmoor Community Services District, the Applied Music Studio and any other entity associated with the program, their officers, agents and employees from any liability, claim or action arising out of such participation. I understand that this program is not bound by the responsibilities and legalities that accompany a licensed daycare program. I further certify that my child is in good health and has no physical or other impediment which would endanger him/her or any other participant in taking part in such an activity.

CONSENT TO TREAT A MINOR

I certify that I am the parent or legal guardian of the child being enrolled in this program. I hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis rendered under the general or special supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medicine Practice Act or Dentist licensed under the provisions of the Dental Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Public Health. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care required but is given to provide authority and power to tender care which the aforementioned physician in the exercise of his/her best judgment many deem advisable. It is understood that effort will be made to contact the undersigned prior to rendering treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached. This authorization is given pursuant to the provisions of section 25.8 of the Civil Code, State of California.

I hereby authorize the staff of the Youth Center to provide immediate first aid to my child in the event of illness or injury. In addition, if this program provides for the transportation of my child, I hereby grant permission to the Youth Center to provide such transportation. Lastly, I hereby give the Los Alamitos Youth Center, Inc., it's successors and assigns, the absolute and irrevocable right and permission with respect to photographs, videos, motion pictures, and /or sound recordings being taken of my child: (a) to use, reuse, publish and republish in whole or in part and (b) to use my child's name. I further release the Youth Center from any claims and demands arising out of the use of same.

Allergies to Food or Drugs:

Are there any medical issues or medications at the school office that we should be aware of?

Emergency Contact:

Relationship:

Best Emergency Contact Phone Number:

EARLY REGISTRATION SAVINGS!

Register before September 1

3-5 day a week ($40/month - $360 total) or Pay in Full - $250 ($110 Savings) 1-2 day a week ($20/month - $180 total) or Pay in Full - $125 ($55 Savings) 1-2 day a month ($5/month - $45 total) or Pay in Full - $30 ($15 Savings)

Register after September 1

3-5 day a week ($50/month - $450 for year) or Pay in Full - $350 ($100 Savings) 1-2 day a week ($25/month - $225 for year) or Pay in Full - $175 ($50 Savings) 1-2 day a month ($10/month - $90 for year) or Pay in Full - $45 ($18 Savings)

Credit Card Number:

Expiration Date (Mo/Yr)should not expire before April:

Name on Card:

Please be sure you've typed the Validation code correctly. If you don't, your form will be erased.Validation: